The best ED in the world: it depends on your point of view. Or does it?

What would make an ED the best in the world? If we set out to build one from scratch, what would it be like? I think it depends who you ask, because you’ll get different responses.

Should you ask emergency staff? Those who would get to work in the best ED?

Initially we’d tell you we need better staffing and resources – more nurses, more beds, quicker transit times to the wards to prevent obstructions to ‘flow’. These are true answers, but given enough time to whinge, we’d provide answers that are a little more honest – we’ll tell you we want IT systems that are reliable and do what we want them to do. We want to see ultrasound reports before the patient dies of old age. We want the onslaught of presentations to slow enough to allow us to do those tasks well that take a little while. A bit after that, maybe after a few drinks at the Christmas party, we’ll tell the deeper truth of the matter – we want an ED where inter-disciplinary obstructionism isn’t a perennial pain in the behind, and where hospital-wide announcements about bed pressure isn’t an everyday occurrence. Maybe, we’d declare in the heat of our angst, the best ED is one that’s attached to a hospital whose management gives a toss about good emergency care.

Also, the coffee should be free.

That’s all fair, I think, but maybe we shouldn’t be the ones to be asked. After all, you wouldn’t ask a pilot to design a plane – there’d be a jacuzzi in the cockpit and they’d never get anything done.

What would the rest of the hospital say?

I think they’d all like an ED with a little more self-sufficiency. The ICU would prefer an ED that didn’t get snippy about having a ventilated patient in one of their four resus bays all night. To the orthopaedic team, the best ED wouldn’t worry so much about having to sedate a patient for a third time so that they can have another go at reducing the distal radius fracture instead of booking into the emergency theatre.

Not everything they’d like is out of the question I suppose. I’m sure the radiologist reading that ultrasound from before would like the ED that put more than ‘exclude pathology’ on its request forms. Some of the inpatient registrars do 36 hour shifts and could probably also do with less 4am calls about things that could wait until 7.

What about the patients? What would the ED look like that made their stay less distressing?

It wouldn’t be so full all the time, with waiting for hours on end before seeing a doctor. Pain, nausea, and anxiety would be managed well, and information would be explained frankly but with enough detail to make some sense.

Specialist services would be available (and not overrun) and when patients need to be admitted, they’d like their stay in emergency to be over as soon as it could be, instead of haunting the fluorescent limbo of the ED ‘awaiting bed’.

Maybe these responses aren’t so different from each other – we all want a functional emergency department – where people can be seen on time, managed thoroughly, and where there aren’t enormous delays to getting home or to the ward.

While everyone’s blaming everyone else for the inefficiencies, the common thread is often under-resourcing and facilities that are out of date before they even open. The inpatient teams are struggling with their own packed wards and lists. The ICU can’t accept that patient because there is physically no space to plug in the ventilator, and the radiologist is still looking at the last seven pan-scans.

In the best ED in the world, we’d all recognise that the friction of struggling against each other is wasted energy, and that using our limited resources better is the only way to make our EDs excellent.